Modest agreement in ECG interpretation limits the application of ECG screening in young athletes

Heart Rhythm. 2015 Jan;12(1):130-6. doi: 10.1016/j.hrthm.2014.09.060. Epub 2014 Oct 5.


Background: Athlete ECG screening has been recommended by several international sporting bodies; however, a number of controversies remain regarding the accuracy of ECG screening. An important component that has not been assessed is the reproducibility of ECG interpretation.

Objective: The purpose of this study was to assess the variability of ECG interpretation among experienced physicians when screening a large number of athletes.

Methods: A sports cardiologist, a sports medicine physician, and an electrophysiologist analyzed 440 consecutive screening ECGs from asymptomatic athletes and were asked to classify the ECGs according to the 2010 European Society of Cardiology criteria as normal (or demonstrating training related ECG changes) or abnormal. When an abnormal ECG was identified, they were asked to outline what follow-up investigations they would recommend.

Results: The reported prevalence of abnormal ECGs ranged from 13.4% to 17.5%. Agreement on which ECGs were abnormal ranged from poor (κ = 0.297) to moderate (κ = 0.543) between observers. Suggested follow-up investigations were varied, and follow-up costs ranged from an additional A$30-A$129 per screening episode. Neither of the 2 subjects (0.45%) in the cohort with significant pathology diagnosed as a result of screening were identified correctly by all 3 physicians.

Conclusion: Even when experienced physicians interpret athletes' ECGs according to current standards, there is significant interobserver variability that results in false-positive and false-negative results, thus reducing the effectiveness and increasing the social and economic cost of screening.

Keywords: Electrocardiography; Interpreter variability; Screening; Sudden cardiac death.

MeSH terms

  • Adolescent
  • Adult
  • Arrhythmias, Cardiac / complications
  • Arrhythmias, Cardiac / diagnosis*
  • Arrhythmias, Cardiac / physiopathology*
  • Athletes*
  • Cohort Studies
  • Death, Sudden, Cardiac / etiology*
  • Electrocardiography*
  • Female
  • Humans
  • Male
  • Mass Screening
  • Observer Variation
  • Reproducibility of Results
  • Risk Factors
  • Young Adult